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CPTP > Parkinsons and Epilepsy > Flashcards

Parkinsons and Epilepsy Flashcards

1
Q

Parkinsons disease

A

Neurodegenerative disorder consisting of loss of dopaminergic neurones in the substantia nigra leading to degeneration of projections

1% incidence, increases with age and male gender

PC - bradykinesia, resting tremor, rigidity and postural instability. Autonomic symptoms of postural hypotension, urinary incontinence, constipation and erectile dysfunction

1st symptoms = anosmia, depression/anxiety, sleep disturbance,

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2
Q

Parkinsonism

A

Clinical signs and symptoms of PD may be caused by MSA, huxngtingtons or small vessel ischemia

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3
Q

Sites for medication to act in PD

A

Levodopa - replaces missing dopamine
Monoamine oxidase inhibitors - prevent dopamine breakdown
Dopamine agonists - mimic dopamine actions by binding to the post synaptic receptor
COMT inhibitors - prevent breakdown at synaptic cleft

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4
Q

L-dopa (madopar = co-careldopa) MOA

A

Precursor for dopamine given with decarboxylase inhibitor to prevent its breakdown peripherally. Without this only 5% would reach the brain and SE of dopamine peripherally would be N/V, arrhythmias and postural hypotension

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5
Q

Short term SE L-dopa

A

N/V, reduced appetite
Somnolence, insomnia and vivid dreams
Postural hypotension - vasodilation of cardiac vessels

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6
Q

Long term SE L-dopa

A

Motor compilations 50% pt @ 5 years = wearing off of dose requiring increase strength preparations, on off switching and freezing

Dyskinesia = continual writhing, rocking or fighting movements. Dose related. To reduced effects take with meals, small frequent doses and use adjunct medications

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7
Q

CI L-dopa

A

Heart failure, arrhythmias. Closed angle glaucoma

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8
Q

Interactions of L-dopa

A

MAOI’s increased risk of hypertensive crisis
Antihypertensives = increased effect

Warn pt about driving or operating heavy machinery due to drowsiness or dyskinesia

Don’t abruptly stop taking medication = rhabdomyolysis or neuroleptic malignant syndrome

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9
Q

Dopamine agonists (Ropinerole or rotigotine)

A

Mimics effect of dopamine by binding to post synaptic receptors in striatum. Not used in elderly due to reduced efficacy compared to L-dopa and can have increased psychotic effects

1st line in patients <70y/o newly diagnosed

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10
Q

SE of dopamine agonists

A

Somnolence, confusion and hallucinations
N/V and reduced appetite

Impulse control disorders 15% hyper sexuality, gambling, shopping sprees

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11
Q

CI drugs in PD

A

Dopamine antagonists = haloperidol

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12
Q

Mono-amine oxidase B inhibitors (Selegline/rasagiline)

A

Irreversibly inhibit MOAB the specific enzyme for dopamine breakdown after reuptake from the synaptic cleft

Used as an adjunct to L-dopa

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13
Q

SE of MAOBi

A

N/V, confusion and insomnia, postural hypotension

Increase risk of serotonin syndrome

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14
Q

Catechol-O-methyl-tranferase inhibitors (Entacapone)

A

Inhibit COMT, this enzyme is responsible for breakdown of dopamine at the synaptic cleft. Prolongs its action at the post synaptic receptor

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15
Q

SE COMT

A

Increased risk of dyskinesias, diarrhoea, reddish brown urine. Tolcapone is more effective but increased risk of hepatotoxcity

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16
Q

Amantidine

A

Acts as a minor antimuscarinic, stimulating dopamine release and inhibiting its reuptake. Can reduced dyskinesia

SE = ankle oedema, postural hypotension and confusion

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17
Q

Treatment of PD 50-60y/o and >70y/o

A

<70y/o and new diagnosis = MAOI and dopamine agonists. L-dopa sparing strategy

> 70y/o / comorbidities = L-dopa +/- MAOBi or COMT

If severe dyskinesia reduce dose of L-dopa and start amantadine

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18
Q

Mx PD complications

A

Anxiety/ insomnia = CBT, SSRI’s, Zopiclone
Constipation = hydration, laxatives
Nocturne and incontinence = catheter?

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19
Q

Drug induced Parkinsons

A

Dopamine antagonists = haloperidol, metacloprimide

Lithium, sodium valproate, fluoxetine

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20
Q

Hypertensive emergency vs Hypertensive crisis

A

Emergency = High blood pressure and acute impairment of 1+ organ systems

Hypertensive crisis = BP >180 no evidence of organ damage

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21
Q

PC hypertensive emergency and Mx

A

Retinal haemorrhages and papilloedema
increased ICP = headache, vomiting, low GCS,
Acute renal failure = haemturia and proteinuria

Mx IV sodium nitroprusside

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22
Q

Complications of HTN emergency

A

Hypertensive encephalopathy, CVA, inter cranial haemorrhage. MI, LV dysfunction, AKI

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23
Q

Causes of HTN emergency

A

Pregnancy, cocaine, Phaechromocytoma, head trauma, dopamine agonist, MAOI, renal artery stenosis

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24
Q

Epilepsy and seizures definition

A 
Epilepsy = predisposition to having seizures
Seizure = A clinical symptom caused by abnormal electrical discharge in the brain
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25
Q

Generalised seizures

A

Loss of consciousness, discharge over the entire cortex
Include absence seizures, tonic-clonic, myoclonic

Mx = sodium valproate

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26
Q

Partial seizures

A

Focal onset, consciousness maintained
Simple and complex - then can turn into generalised seizures

Often demonstrate automatism seen due to activity at temporal lobe = smacking of lips, chewing, clapping of hands. Can include olfactory hallucinations

Mx = carbamazepine

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27
Q

Causes of epilepsy

A

Congenital - cerbral palsy, idiopathic, head injury, post stroke or meningitis

28
Q

Guide to epilepsy Mx

A

Antiepileptics prescribed after 2x distinct episodes
Monotherapy unless treatment resistant
Never withdraw abruptly
Seizure of any type inform DVLA

29
Q

Causes of Seizures

A 
Vascular = stroke, SAH
Infections = sepsis, meningitis, encephalitis
Trauma = head injury
Metabolic = hypoglycemia, hypo/hyperthermia, electrolyte abnormalities, hypoxia
Inflammatory = amyloidois, alzheimers
Neoplastic = SOL
Doctors = drugs cocaine, MDMA, alcohol,
30
Q

Sodium Valproate MOA

A

Valproate acts on Na+, Ca2+ channels and GABAa receptors. It inhibits GABA transaminase therefore increasing GABA level leading to neuronal inhibiton

31
Q

Sodium Valproate uses

A

1st line for idiopathic generalised epilepsy, myoclonic and absent seizures

32
Q

SE sodium valproate

A

wt gain, N/V, impaired glucose tolerance, tremor
Highly teratogenic don’t use in pregnancy
Can = acute liver failure monitor LFT’s 6 monthly
thrombocytopenia
pancreatitis
Hyperammonemia = risk of encephalopathy

33
Q

Interactions of sodium valproate

A

CYP450 inhibitor = increased effect of warfarin, theophylline, lamotrigine

34
Q

Ethosuximide

A

Blocks specific Ca2+ channels that are active in generalised seizures. Used 1st line for children with absent seizures

35
Q

Drugs to avoid in absent/myoclonic seziures

A

Carbamazepine, phenytoin, gabapentin and pregabalin

36
Q

SE of ethosuximide

A

GI upset, eosinophilia, potentiation of tonic clonic seizures

37
Q

Carbamazepine MOA

A

Blocks voltage gated Na+ channels reducing membrane excitability preventing the propagation of action potentials. Opens K+ channels promoting GABA release.

38
Q

Carbamazepine 1st line

A

All partial seizures and trigeminal neuralgia

39
Q

SE Carbamazepine

A

Skin reaction and rash, can = SJS
Dose related = ataxia, diplopia and vertigo/dizziness
Osteomalacia and folate defence
leukopenia and thrombocytopenia

40
Q

Interactions of carbamazepine

A

Enzyme inducer - can induce its own metabolise soma need to gradually be titrated up during initial weeks of Mx

41
Q

CYP450 inhibitors

A

Sodium valproate, isoniazid, macrolides amiodarone, SSRI, quinolones, PPI, grapefruit

42
Q

CYP450 inducers

A

Carbamazepine, phenytoin, theophylline, rifampicin, ST johns wart

43
Q

Phenytoin MOA

A

Blocks propagation of action potentials by preferentially blocking excitation of neurones that are repeatedly firing. Discourages spread not initiation. Acts on Na+ channels

Enzyme inducer so dose may need to be titrated up, reduces effective dose of other drugs

44
Q

Uses of phenytoin

A

Status epileptics and myotonic dystrophy

45
Q

SE of phenytoin

A

Narrow therapeutic window so can = toxicity
gingival hypertrophy due to inhibition of collagen catabolism. Acne, hirsutism, insomnia, peripheral neuropathy, tremor, dyskinesia

Macrocytic anaemia due to increasing folate metabolism, osteomalacia due to increased vit d metabolism

46
Q

Screening of chinese/thai on phenytonin

A

HLAB-1502 gene which gives a increased incidence of SJS

47
Q

Acute phenytoin toxicity PC

A

Severe cerebellar signs - ataxia, diplopia, dysmetria, nystagmus, dysdokinesia
Drowsiness, needs cardiac and BP monitoring

IV phenytoin may - hypotension, arrhythmias, cardiac and rep depression

48
Q

CI to phenytonin

A

Teratogenic, HLAB-1502 +ve, heart block

49
Q

Lamotrigine MOA

A

Stabilises pre-synaptic neuronal membranes by blocking voltage gated Na+ and Ca2+, reducing the release of glutamate and excitatory neurotransmitter

Alternative for generalised and partial epilepsy safest in pregnancy!

50
Q

SE lamotrigine

A

Increased incidence of SJS and TEN, 10% of people experience a rash (start low and increase dose gradually)
GI disturbance

Stop if signs of rash, monitor LFT’s and FBC

51
Q

Levertircetam

A

Future drug of choice. Inhibits synaptic vesicle protein 2A reducing vesicle recycling and inhibiting presynaptic Ca2+ channels

Well tolerated, few drug interactions. Renally excreted

52
Q

SE Levertircetam

A

labile mood, somnolence, behavioural disturbance and psychosis

53
Q

COCP and antiepileptics

A

Reduced efficacy of COCP = carbamazepine, phenytoin

COCP reduces the efficacy of lamotrigine

Use increased strength COCP 50micrograms or mirena coil as alternative

54
Q

Benzodiazepines (diazepam/midalozam) MOA

A

Agonists to the benzodiazepam receptor on GABA receptor complex. High affinity for GABA receptor bind causing Cl- channels to open hyperpolarising the membrane preventing further excitation.

55
Q

Uses of benzodiazepines

A

Status epilepticus, alcohol withdrawal - seizures prophylaxis, sedation, short terms anxiety relief

56
Q

SE benzodiazepines

A

Confusion, amenesia, hypotension
Can = respiratory depression
If long term lead to dependence

If overdose = IV flumazenil

57
Q

Status epilepticus

A

5+ minutes of seizure activity or several recurrent seizures in 30mins

58
Q

Mx status epilepticus

A

ABCDE - protect airway. Check glucose = hypoglycaemia is a common cause of seizures

IV lorazepam 0.07mg/kg stat
Alternatives in community = PR diazepam or buccal midolozam

If no improvement in 20mins IV phenytoin 15mg/kg, monitor BP, HR, ECG. Inform ITU

59
Q

Sudden unexpected death epilepsy risk factors

A

Young age, poor control/compliance, generalised tonic/clonic, unwitnessed seizures

60
Q

Pregnancy and anti epileptics

A

High dose folic acid 5mg for all. Lamotrigine is the safest in pregnancy. Aim to give mono therapy at lowest possible dose.

Don’t prescribe valproate

61
Q

Driving and seizures

A

With any seizure not due to a reversible cause i.e. alcohol, drugs or fever cease driving and inform DVLA immediately

1st unprovoked seizure = 6 month ban
Established epilepsy = 1 year seizure free

62
Q

Wernickes encephalopathy

A

Triad of ataxia, confusion and opthalmeplegia - nystagmus. Due to thiamine deficiency seen commonly in alcoholics

63
Q

Korsakoff psychosis

A

Anterograde and retrograde amnesia due to maxillary body infarction due to chronic thiamine deficiency. LTM is maintained. Occasionally confabulation

64
Q

Delirium tremens

A

Alcohol is an inhibitory of the CNS, rapid withdraw leads to reduced GABA = mass overexcitation. Worse 2-3 days post withdrawal

65
Q

Mx acute alcohol withdrawal

A

ABCDE + correct hypoglycaemia
2 x 500mg thiamine IV TDS
IV chlordiazepoxide

66
Q

PC Delirium tremens

A

Confusion, agitation, visual and auditory hallucinations, sweating, tachycardia, hyperthermia, tremors, N/V
Can lead to generalised tonic-clonic seizures.

O/E = high HR and BP, pyrexial, tremor, nystagmus, reduced GCS

67
Q

Antiepileptic hypersensitivity

A

Rare but fatal complication linked to carbamazepine, lamotrigine and phenytoin. Symptoms 1-8 wks post exposure.

PC = fever, rash, lymphadenopathy, liver dysfunction, renal failure

CPTP (11 decks)

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